Changes and Revisions to the Administrative Manual



Contracts and insurance policies necessary to the orderly
conduct of business shall be maintained.The provision of a
service in the absence of a contract is considered to be a
constructive contract and need not be formalized by writing.
However, when the service provided is directly related to
patient care, certain parameters will be adhered to as
described below. 

The original documentation of written contracts will be
stored in a secure location.



It is not necessary that every business relationship be
formalized with a contract. However, Leadership of this
organization assures oversight of contracted services for
provision of patient care for safety and effectiveness. (E.g.
anesthesia services, pathology and clinical laboratories,
diagnostic radiology services)

Monitoring activities of patient care contractual agreements
will focus on safety and quality of the contracted service.

Leadership must approve of the source of the clinical
services(s) to be provided through the contract.

The nature and scope of services provided through patient
care contractual agreements are described in writing and are
part of the contract or part of the privileging list as
Expectations are established for the performance of patient
care contracted services and are part of the actual contract
or privileging list as applicable.

Expectations are communicated in writing to the contracted
service for patient care.

Leadership monitors or evaluates the contracted services for
patient care in relation to these expectations annually or
more often if indicated.Monitoring is accomplished by:

Reviewing information regarding accreditation or
certification status as in the case of laboratories

Direct observation of the provision of care

Audit of documentation, including medical records (E.g. peer

Review of Incident reports

Collection of data that addresses the efficacy of the
contracted service (See the QI section of the website,
Mandatory audits Test Results)

Reference and contract lab services meet the applicable
federal regulations for clinical laboratories and maintain
evidence of the same. 

When the expectations are not met, leadership takes steps to
improve the contracted services by stating improvements
desired in writing to the organization with a cure period,
renegotiating or terminating the contract when the continuity
of patient care is not maintained. 

Examples of contracts which may be a part of our records

1.Pathology Services,You must have a contract with each
lab as well as their CAP certificate or state license.

2.Linen Contract 

3.Infectious Waste Disposal Contract 

The organization must also maintain the document that is
returned to the organization stating the infectious waste
was disposed of properly.All receipts of pick up and
disposal must be stored in one file folder.

4.Air Conditioning 



7.Fire Extinguisher (contract or bill of sale)


9.Nursing Registry

10. Bio-Medical Engineering Services Contract 

11. General Waste Disposal Contract 

12. Hospital Transfer Agreement or agreement with an
ambulance or documentation of efficacy of 911 call.Such
agreement must be proven efficient. 

13. Independent Contractor Confidentiality Contract 

14. Business Associate (HIPAA) 

Insurance policies will be established, maintained, and
updated on a timely basis.Insurance policies will be kept
in a secure location in the Administrative office.Examples
of insurance policies include:

1.Professional Liability
2.Fire Insurance Policy
3.General Liability Insurance Policy (including fire and
premises liability)
4.Workers Compensation Insurance
5.Personal Liability Policy, when appropriate


Approved By Governing Board


Control #1.1